Provider Demographics
NPI:1225152580
Name:BROOKHAVEN EAR, NOSE & THROAT PA
Entity Type:Organization
Organization Name:BROOKHAVEN EAR, NOSE & THROAT PA
Other - Org Name:MISSISSIPPI SINUS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:COREY
Authorized Official - Last Name:CASE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-835-0077
Mailing Address - Street 1:201 S RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3331
Mailing Address - Country:US
Mailing Address - Phone:601-835-0077
Mailing Address - Fax:601-835-0095
Practice Address - Street 1:201 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3331
Practice Address - Country:US
Practice Address - Phone:601-835-0077
Practice Address - Fax:601-835-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10309207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08837378Medicaid
MSC04608Medicare PIN